Who controlled the use of guns in County Durham?
A coroner's lot is to deal with death.
Behind the verdicts they record, some will have been tragic accidents, some premeditated acts of violence.
Perhaps the most difficult are the ones that were preventable.
According to coroner Andrew Tweddle the killing spree at Horden on New Year's Day 2012 by Michael Atherton was "avoidable".
The triple murder of Susan McGoldrick, Alison and Tanya Turnbull was horrific, but the coroner was so concerned about the way gun licensing was administered by Durham Police he publicly called for "root and branch" reform.
The inquest heard there were numerous opportunities to revoke Atherton's permit to own weapons.
As we exclusively revealed in November 2012 this is on top of criticism by the Independent Police Complaints Commission who found there was a "wanton lack of intrusive enquiries, poor practice and woeful record keeping" within Durham Police's firearms licensing unit.
Sadly, even this was not the first time Inside Out had reported on the lax approach to way the Durham force dealt with guns.
In 2010 we exposed the background to the trial of Maurice Allen.
The PC, along with fellow officer Damian Cobain, was convicted of misconduct in a public office.
They'd been selling guns handed in to the police for destruction.
Before he was convicted Inside Out undertook an interview with Allen in which he blew the whistle on how badly the department was being run.
The judge in his case described gun control within the police as "chaotic".
At that time Michael Barton, a senior officer who has since become chief constable, admitted to me: "This was not our finest hour was it?"
He reassured viewers that things had changed.
What we didn't know back in 2010 was the same gun licensing team had been reviewing Michael Atherton's gun licences. Among the team was Damian Cobain.
It's a connection that the public nearly didn't find out about.
It was only after a press intervention during the inquest hearing that an order banning officers' names from being revealed was lifted.
Things have definitely changed now. The inquest heard that since the Horden shootings, Durham Police has reviewed the existing gun licenses and more than 100 have been revoked.
For the family the inquest is not closure.
We can all only hope that past mistakes at Durham Police have been corrected.
The family's eye now is on the future.
I was struck from the first time I met them at the dignity that have shown in the face of the colossal tragedy that hit them.
Bobby Turnbull has coped remarkably well with being reluctantly thrust into the media spotlight.
I was at the National Victims' Association conference at which he summoned the courage to speak about his mother, sister and aunt's killings.
He and the family were determined lessons should be learned and our gun laws reformed.
They are hoping an e-petition will gather enough support to lead to change.